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  5. Right Dose in Computed Tomography

CARE Right“Committed to ALARA“ VS. “Admitting to guesswork” – Second best is not an option.

CARE Right

Taking Low Dose to the Next Level
In medical imaging it is essential to provide sound and sustainable clinical results with highest patient safety. When it comes to applying radiation, ALARA - As Low As Reasonably Achievable - is the overarching principle.
For years, Siemens has been at the forefront of radiation reduction. Continuous dedication and unique technological advances have made Siemens CT the low dose leader to catch. Thanks to these efforts, scans at sub-mSv doses found their way into clinical routine.
But as such low doses become achievable, one has to verify whether 1 mSv actually is the right dose for every patient. Obviously, there isn’t one dose level that fits everyone. Every clinical question and every single patient demands an individual and specific dose level. Therefore, while everybody is only talking about low dose, Siemens is convinced that what really matters is the right dose.

CARE Right. Committed to the Right Dose in CT

The right dose is the reasonable balance between applied radiation and image quality. In order to help customers achieve this balance, Siemens is introducing CARE Right.


This holistic approach is based on the belief that after the recent innovations in radiation reduction, a singular focus on low dose only is not sufficient anymore. Consequently, efforts must now be targeted towards a comprehensive understanding of the right dose. Thus, CARE Right encompasses three key areas:

  • Right Dose Technology
  • Right Dose Levels
  • Right Dose Management

With this, Siemens CT is not only adhering to the ALARA principle, but is inspired by it.


Discover CARE Right. Committed to the right dose in CT.

Right Dose Technology

Right Dose Technology

Enable the Right Dose with Best-in-Class Technology
In order to reduce radiation to the right dose, of course, the first prerequisite is still the appropriate hardware: healthcare institutions need the right technology. Siemens has a long tradition of being an innovation leader in CT technology: whether it was the introduction of CARE (Combined Applications to Reduce Exposure) in the 1990s, Dual Source CT in the 2000s, or the Stellar Detector in the 2010s, Siemens has continuously been one step ahead. Therefore, it was a logical consequence that Siemens was named “the low dose leader to catch” when its SOMATOM Definition Flash won the 2011 Best in KLAS award.1 Overall, this was due to the fact that Siemens offers a comprehensive and innovative portfolio of unique dose reduction features:

 

Focus on the Individual Patient and Examination
In order to achieve the right dose for a patient, there are three important factors to consider: the size and stature of the patient, the type of examination, and the applied radiation dose. With Siemens’ technology, all of these aspects can be addressed:

CT – Technologies – ADMIRE – Advanced Modeled Iterative Reconstruction

ADMIRE (Advanced Modeled Iterative Reconstruction) our latest right dose technology and the next generation in iterative reconstruction from Siemens. ADMIRE sets a new benchmark in iterative reconstruction instead of limiting its potential for clinical routine.

SAFIRE

SAFIRE (Sinogram Affirmed Iterative Reconstruction) finally made it possible to benefit from iterative reconstruction with a dose reduction potential of up to 60%2 in clinical routine, even in environments where time is crucial, such as acute care.   

CARE Dose4D

CARE Dose4D, for example, offers real-time anatomic exposure control. This allows adjusting the dose modulation according to the patient’s anatomy and position during the scan.

CARE kV

CARE kV offers an automated dose-optimized selection of the x-ray tube voltage (kV) depending on the selected type of examination. It is the industry’s first tool that automatically determines the appropriate kV and scan parameter settings to help deliver the right dose for a particular scan and the user defined image quality.

Find more technologies:

More information about SAFIRE2

For quite some time, iterative reconstruction has been heavily discussed in the CT community as a highly promising method to achieve significant dose reduction without compromising image quality. And once again Siemens has set the benchmark on low dose imaging with the introduction of the first raw-data based iterative reconstruction – SAFIRE. For the first time, raw data (or sinogram data) are actually being utilized in the iterative image improvement process. With this, SAFIRE can achieve a radiation dose reduction of up to 60%2. Or instead improve image quality (contrast, sharpness and noise), even surpassing the already impressive image quality realized with IRIS.

SAFIRE (Sinogram Affirmed Iterative Reconstruction)

SAFIRE in 3 steps:

1. Multiple iterative loops performed in the raw-data domain correct geometrical imperfections and other artifacts
2. Image reconstruction from the “corrected” raw-data
3. Multiple iterative loops performed in the image domain remove image noise for a final and excellent image quality

 

 

 

SAFIRE Clinical benefits:
1. SAFIRE allows dose reduction in a wide protocol spectrum
2. Provides a excellent image quality
3. Fast and customizable workflow with up to 20 images per second

IRIS (Iterative Reconstruction in Image Space)

Because at Siemens dose reduction has continued to be give top priority for both patients and medical staff. We can now introduce another low dose solution – once again Siemens has set the benchmark on low dose imaging with the introduction of iterative reconstruction. IRIS delivers excellent image quality with lower dose levels. With IRIS, Siemens’ smart approach to iterative reconstruction, dose reduction can be achieved in a wide range of daily routine CT applications.3

Dose reduction with CT has been limited by the currently used filtered back projection reconstruction algorithm as displayed on the left. When using this conventional reconstruction of acquired raw data into image data, a trade-off between spatial resolution and image noise has to be considered. Higher spatial resolution increases the ability to see the smallest detail; however, it is directly correlated with increased image noise.

In an iterative reconstruction, a correction loop is introduced into the image generation process as shown on the right. To avoid long reconstruction times the new Iterative Reconstruction in Image Space first applies a raw data reconstruction only once. During this initial raw data reconstruction, a so-called and newly developed master volume is generated that contains the full amount of raw data information, but at the expense of significant image noise. During the following iterative corrections the image noise is removed without degrading image sharpness. The new technique results in increased image quality or dose savings for a wide range of clinical applications.

 

Dose Shield

The Adaptive Dose Shield - available on the SOMATOM Definition Edge and SOMATOM Definition Flash - eliminates over-radiation pre- and post-spiral to the patient (marked in red). It is unique to the CT industry and part of the innovative new STRATON X-ray tube design. By dynamically moving shields into place on the X-ray tube it blocks clinical irrelevant dose. The Adaptive Dose Shield dynamically opens at the beginning of a spiral range and then dynamically closes at the end. Now all clinically irrelevant dose is eliminated. Not only for dedicated applications, but for every single spiral acquisition.3

Right Dose Levels

Right Dose Levels

Scan at the Right Dose Levels
Next to having access to the right technology, it is essential to know the right dose levels to perform an examination according to ALARA (As Low As Reasonably Achievable). The right dose level is the best possible balance between image quality and required amount of radiation.

 

Absolute Dose Values - Essential for the Right Dose
A prerequisite for users to know whether they apply the right dose levels is an understanding of absolute dose values. This is why Siemens provides them along with their protocols. Users can then use these values as a reference to compare their current dose level with regional recommendations and guidelines, scientific publications, or the dose levels delivered by Siemens CT standard scan protocols.

SIERRA

SIERRA – the Siemens Radiation Reduction Alliance – was founded by Siemens together with key opinion leaders in radiology. Comprised of 15 international experts, this alliance creates recommendations for clinical practice around the globe.

CT Scan Protocols

Siemens CT Standard Scan Protocols apply these recommendations to each examination. Along with international guidelines and reference values, Siemens’ dedicated protocol development team continuously incorporates the feedback from panels like SIERRA into a sophisticated library of scan protocols.

More information about SIERRA

In a continual commitment to patient care and radiation reduction in computed tomography (CT), Siemens Healthcare has launched SIERRA (Siemens Radiation Reduction Alliance) and has established an expert panel to advance the cause of dose reduction in CT. The new Low Dose Expert Panel includes 15 specialists in radiology, cardiology and physics, who are internationally recognized for their publications on the subject of CT dose. The panel’s objective is to generate proposals for how manufacturers may continue to develop their technology and to help users better adapt their procedures in order to bring about further dose reduction in CT. One of the most important suggestions from the first meeting of the Low Dose Expert Panel in May concerns methods to increase utilization in clinical practice of the many CT dose reduction technologies that are already available.

SIERRA’s expert panel proposes its first recommendations on patient care, radiation reduction

“Our aim as a leading innovator in the field of computed tomography is to reduce radiation exposure for all typical CT examinations below 2 mSv, which is as low as the average annual dose due to naturally occurring background radiation. We are committed to doing everything we can to help our customers reduce doses in CT without compromising the diagnostic quality of the examination in any way,” said Sami Atiya, PhD, former CEO, Computed Tomography, Siemens Healthcare. “With this in mind, we want to work with experts to develop concrete proposals on dose reduction and, therefore, launched Siemens Radiation Reduction Alliance, SIERRA.”

Excellent image quality is vital in CT, but it is also important to keep the patient’s radiation exposure as low as possible. Siemens Healthcare has already introduced a wide range of measures to help its customers consistently achieve this goal. Now, Siemens wants to take on a more active role in this field and has convened a panel of experts expressly to develop new ideas for dose reduction in CT.

The Low Dose Expert Panel will meet twice a year to discuss new ideas and investigate whether measures already agreed upon are having a positive impact. Siemens intends to use the discussions to spur the development of new features for its CT scanners and new training programs for its customers.

The panel’s members are:
Hatem Alkadhi, MD, University Hospital Zürich, Switzerland
Christoph Becker, MD, Ludwig Maximilian University, Germany
Elliot Fishman, MD, Johns Hopkins University, U.S.
Donald Frush, MD, Duke University, U.S.
Jörg Hausleiter, MD, Ludwig Maximilian University, Germany
Willi Kalender, PhD, University of Erlangen, Germany
Harold Litt, MD-PhD, University of Pennsylvania, U.S.
Cynthia McCollough, PhD, Mayo Clinic, U.S.
Alec Megibow, MD, NYU-Langone Medical Center, U.S.
Michael Recht, MD, NYU-Langone Medical Center, U.S.
Dushyant Sahani, MD, Harvard Medical School, Massachusetts General Hospital, U.S.
U. Joseph Schoepf, MD, Medical University of South Carolina, U.S.
Marilyn Siegel, MD, Mallinckrodt Institute of Radiology, U.S.
Aaron Sodickson, MD-PhD, Brigham and Women’s Hospital, U.S.
Kheng-Thye Ho, MD, Tan Tock Seng Hospital, Singapore

What experts say about SIERRA

Schoepf Joseph CT Expert

"Radiation dose from medical imaging has historically received much greater attention in Europe than in other parts of the world, where radiation exposure only recently has become a topic of discussion. On that background, Siemens has several decades of experience in the implementation of radiation reduction strategies and has a longstanding, successful track record of providing their customers with tools that deliver optimal image quality at the lowest possible radiation dose. Most of the technical features and mechanisms for radiation reduction which regulatory bodies currently consider making mandatory in the U.S. have been part of their standard portfolio and implemented in their products for many years. I am happy and proud to embark on this initiative together with Siemens and my colleagues from around the globe in order to ensure that these powerful tools are used to their fullest extent. With this endeavor we can make a difference and show to the world that we do get the message, that we can indeed change, and slash radiation dose without sacrificing diagnostic quality."
U. Joseph Schoepf,
MD, Medical University of South Carolina, Charleston, U.S.

McCollough

“I see users operating CT scanners in everyday applications without taking full advantage of the possibilities available to them to strike the optimal balance between image quality and radiation dose. The answer, in my opinion, involves a significant amount of training across a wide range of areas. I want to see users at more and more institutions receive the advanced training they need in order to make best use of the options available, and this will be the main objective of my work on the panel.”
Cynthia McCollough,
PhD, Mayo Clinic, Rochester, Minn, U.S.

Dr. Siegel

"We have made great advances in optimizing pediatric radiation doses, but dose reduction optimization remains a work in progress. Advances in technology and capabilities of CT scanners will continue to evolve and improve our ability to diagnose disease. These advances will mandate new scanning protocols and continuing education for users. By collaborating with industry, we can optimize CT scanning in children even further and continue to improve patient care. I am delighted to join Siemens in an initiative to develop protocols and integrate new technologies into clinical practice."
Marilyn Siegel,
MD, Mallinckrodt Institute of Radiology, St. Louis, U.S.

Low Dose Protocols

In order to optimize your clinical protocols, you can download protocols shared by colleagues.
How to import Protocols

mayo clinic low dose protocol

Mayo Clinic Protocol

Mayo Clinic Researchers Share Latest Findings
in CT Radiation Dose Reduction Efforts
Recent presentation reports promising results, while
new clinical protocol drops dose almost 50 percent.

Right Dose Management

Right dose management

Continuously Optimize Dose with the Right Dose Management
In order to establish consistent dose levels, organizations need to be able to sustainably manage dose across their institutions. They may also be required to document and report dose applied to patients due to regional regulations.

The Right Tools for Sustainable Dose Management
All of these requirements rely on the availability of dose data and adequately educated personal. These two aspects are at the core of Right dose management, which further optimizes dose reduction

DoseMAP - Siemens CT Dose Management Program – provides functionalities like CARE Analytics to report, document, and analyze dose. It lets the user access dose values per case, per examination type, or per patient. Additionally, access to scan protocols can be restricted to protect the set dose levels and to prevent unauthorized changes to the scan parameters.

EduCARE bundles dedicated trainings from Siemens that focus on key technologies and their application in clinical practice. Exclusive tutorials, webinars, e-trainings, and brochures cover a wide range of topics related to achieving the right dose.
Clinical Webinars
“How to guides”
e-Learnings

Optimize CARE CT is a consultancy program offered by Siemens Customer Service. Over the course of the program, Siemens professionals guide users towards optimizing the use of radiation in order to reduce dose. Through onsite and offsite support and trainings, users learn how to use the right dose technology to deliver the right dose levels for every patient.

Cases

Clinical Examples: Scanning with the Right Dose

CARE Right aims at finding the right dose for every individual patient. What matters is the right balance between image quality and radiation dose. All of CARE Right’s individual areas – right dose technology, right dose levels, and right dose management – come together in the following examples.

CARE Right. Committed to the right dose in CT.

Clinical cases:

Case 1: Pediatric Case

Pediatric

Diagnosis: Septum defect with impact on lung perfusion?
(Image: Erasmus MC - University Medical Center Rotterdam / Rotterdam, the Netherlands)

   

 

Scan method: thorax dual energy scan and flash spiral scan

Thorax dual energy scan:
Collimation: 64 x 0.6 mm
Spatial resolution: 0.30 mm
Scan time: 2 s
Scan length: 118 mm
TI: 0.28 s
80/140 Sn kV, 26/16 mAs
DLP: 18 mGycm
CTDIvol: 1.28 mGy
Eff. dose: 1.58 mSv

Flash spiral scan:
Collimation: 128 x 0.6 mm
Spatial resolution: 0.30 mm
Scan time: 0.29 s
Scan length: 118 mm
TI: 0.28 s
70 kV, 14 mAs
DLP: 3 mGycm
CTDIvol: 0.15 mGy
Eff. dose: 0.26 mSv

Case 2: CT Abdomen

CT Abdomen

Diagnosis: EVAR with persistent aortic endoleak
(Image: Clinique CIMOP Bizet / Paris, France)




Collimation: 128 x 0.6 mm
Spatial resolution: 0.30 mm
Scan time: 3 s
Scan length: 543 mm
TI: 0.28 s
100 kV, 83 mAs
DLP: 190 mGycm
CTDIvol: 3.29 mGy
Eff. dose: 2.85 mSv

Case 3: CT Abdomen

CT Abdomen

Diagnosis: obese patient after cholecystectomy
(Image: C.I.M. Laennec / Cesson Sevigne, France)
 

 

 

Collimation: 64 x 0.6 mm
Spatial resolution: 0.30 mm
Scan time: 10 s
Scan length: 373 mm
TI: 0.5 s
100 kV, 300 mAs
DLP: 529 mGy/cm
CTDIvol: 13.55 mGy
Eff. Dose: 7.9 mSv

1

KLAS “CT 2011: Focused On Dose” report, 11/2011

Best in KLAS and Leader in the CT 64-slice and above category

“Best in KLAS Awards Medical Equipment and Infrastructure” report, June 2012

www.KLASresearch.com | © 2011 KLAS Enterprises, LLC. All rights reserved.

2
In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. The following test method was used to determine a 54 to 60% dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogenity, low-contast resolution, and high contrast resolution were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed the same image quality compared to full dose data based on this test. Data on file.
3

Results may vary. Data on file.